Column Label Description. Total All Incoming Calls/VDN Report a total for all incoming calls to the Main/Trunk line. <name of split> A separate column needs to be added to the report for each individual Split/VDN maintained for the Main/Trunk line. mm/yyyy The reporting period represented by a two character number for the month (mm) and a four character number for the year (yyyy). Example: January 2012 would be represented as 01/2012. Report #: 12 Created: 02/06/2012 Name: Provider Network File Layout Last Revised: Group: Access/Delivery Network Report Status: Active Frequency: Monthly Exhibits: Period: First day of the month through the last day of the month. Due Date: By the 15th of the month following the report period. Submit To: Kentucky Department for Medicaid Services Description: MCOs should provide MCO Provider Network File layouts as provided in Appendix L of the MCO Contract Appendices. Sample Layout: MCO’s should produce monthly Network Provider files based on the layout requirements in Appendix L of the MCO Contract Appendices. Report #: 12A Created: 02/06/2012 Name: Geo Access Network Reports and Maps Last Revised: Group: Access/Delivery Network Report Status: Active Frequency: Annual Exhibits: Period: Ongoing Due Date: July 31st Submit To: Kentucky Department for Medicaid Services Description: MCO’s should provide the GEO Access Network Reports and Maps on an annual basis or upon request by the Department.
Column Label Description. Member: Beginning Balance Total number of outstanding appeals at the beginning of the first day of the reporting period. Member: Ending Balance Total number of outstanding appeals at the end of the last day of the reporting period. Member: Received: Total Total number of appeals received during the reporting period. Member: Received: Expedited Total number of expedited appeals received within the reporting period broken down by Oral and Written. Member: Received: Expedited: Oral Total number of expedited oral appeals received within the reporting period. Member: Received: Expedited: Written Total number of expedited written appeals received within the reporting period. Member: Received: Non Expedited Total number of non-expedited appeals received within the reporting period broken down by Oral and Written. Member: Received: Non Expedited: Oral Total number of non-expedited oral appeals received within the reporting period. Member: Received: Non Expedited: Written Total number of non-expedited written appeals received within the reporting period. Member: Received: Non Expedited: 5 Working Days Written Notice Provided Total number of written notices provided within five (5) working days for non- expedited appeals. Member: Resolved: Total Total number of appeals resolved during the reporting period. Member: Resolved: Expedited Resolved in 3 Working Days Total of expedited appeals resolved in three (3) or fewer working days. Member: Resolved: Non Expedited Resolved in 30 Calendar Days Total of non-expedited appeals resolved in thirty (30) or fewer calendar days. Member: Resolved: Non Expedited Average Days for Resolution Average number of days to resolve all non-expedited appeals excluding non- expedited appeals extended by fourteen (14) calendar days. Member: Resolved: Written Notice of Resolution within 30 Calendar Days Total number of written notice of resolution that were provided within thirty (30) calendar days of receipt of a non-expedited appeal. Member: Resolved: Expedited An appeal that is required to be resolved within three (3) calendar days). Member: Resolved: Final Disposition Result of the expedited or non-expedited appeal process broken down by upheld, overturned and partially overturned. Member: Resolved: Expedited: Final Disposition: Upheld Total number of expedited appeals that were resolved during the reporting period and were upheld. Upheld means that the prior decision was confirmed and remains as is. Member: Resolved: Expedited: Final di...
Column Label Description. Salary Provide the salary of only the Kentucky’s line of business. MCO may disclose an estimated allocation based on the time allocated to Kentucky. Information related to the Contractor’s ultimate parent company’s Executive Management need not be disclosed. Bonus Unless guaranteed, or actually paid during the report period, bonuses disclosed may be target amounts for the period disclosed expressed as a percentage of base salary. Other Compensation Is limited to other cash compensation actually paid during the reporting period, and may exclude amounts realized or realizable during the period through grant, vesting or exercise of stock options, restricted stock, stock appreciation rights, phantom stock plans, or other long term non-cash incentives. Travel Provide the travel of only the Kentucky’s line of business. MCO may disclose an estimated allocation based on the time allocated to Kentucky. Information related to the Contractor’s ultimate parent company’s Executive Management need not be disclosed. Other Expenses Provide the other expenses of only the Kentucky’s line of business. MCO may disclose an estimated allocation based on the time allocated to Kentucky. Information related to the Contractor’s ultimate parent company’s Executive Management need not be disclosed. Begin Date Provide the begin date of the report period. End Date Provide the end date of the report period. Report #: 53 Created: 09/12/2011 Name: Prompt Payment Last Revised: 09/24/2011 Group: Financial and Information Systems Report Status: Active Frequency: Quarterly Exhibits: NA Period: In accordance with DOI requirements. Due Date: Date Submitted to DOI Submit To: Kentucky Department of Insurance Kentucky Department for Medicaid Services Description: MCOs are required to comply with the Kentucky Department of Insurance (DOI) requirements for prompt payment reporting as referenced in the DOI HIPMC-CP-3 Prompt Payment Reporting Manual. The DOI requires a quarterly submission of the prompt payment report. A copy of the quarterly prompt payment report is required to be submitted to the Department for Medicaid Services (DMS) at the same time the report is submitted to the DOI. Any revisions of the documents submitted to the DOI are also to be submitted to the DMS at the same time. Report #: 54 Created: 08/28/2011 Name: COB Savings Last Revised: 02/27/2015 Group: Third Party Liability Report Status: Active Frequency: Monthly Exhibits: NA Period: First day of month through the last day of th...
Column Label Description. Member Medicaid ID The Member’s Medicaid ID Member Name Concatenate the Member’s ‘Last Name’, ‘First Name’ ‘Middle Initial’. Claim ICN The MCO claim internal control number for the claim being reported. Denied Amount The billed amount the MCO denied due to non-Medicare TPL. Report #: 57 Created: 08/27/2011 Name: Potential Subrogation Last Revised: 02/27/2015 Group: Third Party Liability Report Status: Active Frequency: Monthly Exhibits: NA Period: First day of month through the last day of the month. Due Date: By the 15th of the month following the report period. Submit To: Kentucky Department for Medicaid Services Description: Provides report for cases where the MCO’s Member has had an accident and there is potential for a liable third party or subrogation claim. Sample Layout: Active/Potential Subrogation/Liable Party Member Medicai d ID Member Name Date of Injury Attorney/Liable Party Information Lien/Claim Amount Recovered Amount Status/Closed Date Comments Reporting Criteria: General Specifications Definition Date Format All report dates are to be in the following format: mm/dd/yyyy Sort Order The report is to be sorted in ascending order by ‘Member Name’. Row Label Description NA NA Column Label Description Member Medicaid ID The Member’s Medicaid ID reported as a text string. Member Name Concatenate the Medicaid Member’s ‘Last Name’, ‘First Name’, ‘Middle Initial’ Date of Injury The date of the actual injury/accident. Attorney/Liable Party Information The attorney/liable party name, address and contact information. Lien Claim Amount The MCO lien or claim amount. Recovered Amount The MCO recovered amount from the attorney/liable party. Status/Closed Date Awaiting additional funds or Date case closed if applicable Comments Regarding pending payment or any special circumstance Report #: 58 Created: 08/20/2011 Name: Original Claims Processed Last Revised: 08/29/2011 Group: Claims Processing Report Status: Active Frequency: Monthly Exhibits: A, B Period: First day of month through the last day of the month. Due Date: By the 15th of the month following the report period. Submit To: Kentucky Department for Medicaid Services Description: Provides the number of original clean claims processed during a reporting period reported by Billing Provider Type and claim status. There are four claim statuses to be included in the report:
Column Label Description. Received Total Count Total Count of all Original Claims received during the reporting period. Received Total Processed Total Count of all Original Claims processed during the reporting period to a status of Pay, Deny or Suspended. Received Total Charges Total charges for all received original claims. A claim that pays at the header should use the charges from the header. A claim that pays at the detail should include the charges from all the details. Received Avg. Charges Calculated Field: ‘Total Charges’ from received status divided ‘Total Count’ from received status. Pay Total Count Total Count of all Original Claims that adjudicated to a Pay status. Pay Percent Calculated Field: ‘Total Count’ from pay status divided by ‘Total Processed’ from received status. Pay Total Charges Total charges from original claims adjudicated to a pay status. Header paid claims will use the charges from the Header. Detail paid claims will use charge from the line items that have a pay status. Denied line item charges are not to be included in Total Charges. Pay Avg. Charges Calculated Field: ‘Total Charges’ from pay status divided by ‘Total Count’ from pay status. Pay Total Paid The total adjudicated claim paid amount by the MCO. Example: A claim adjudicated to pay $100. There is an outstanding A/R in financial for $200. The MCO should report the $100 adjudicated paid amount and not the $0 financial payment. Pay Avg. Paid Calculated Field: ‘Total Paid’ from pay status divided by ‘Total Count’ from pay status. Deny Total Count Total Count of all Original that adjudicated to a Deny status. Deny Percent Calculated Field: ‘Total Count’ from deny status divided by ‘Total Count’ from received status. Deny Total Charges Total charges for all denied original claims. A claim that pays at the header should use the charges from the header. A claim that pays at the detail should include the charges from all the details. Deny Avg. Charges Calculated Field: ‘Total Charges’ from deny status divided by ‘Total Count’ from deny status. Suspended Total Count Total Count of all Original Claims that moved to a suspended status. The claim shall be counted even if the claim later was changed to a Pay or Deny status during the reporting period. Suspended Percent Calculated Field: ‘Total Count’ from suspended status divided by ‘Total Count’ from received status. Suspended Total Charges Total charges for all suspended original claims. A claim that pays at the header should use the charges from the h...
Column Label Description. Claim ICN The MCO claim internal control number for the claim being reported. Medicaid Provider ID Medicaid Provider ID reported as a text string. Provider Name Concatenate the Provider’s ‘Last Name’, ‘First Name’ ‘Middle Initial’. Member Medicaid ID The Member’s Medicaid ID Member Name Concatenate the Member’s ‘Last Name’, ‘First Name’ ‘Middle Initial’. Denied Amount The billed amount the MCO denied due to Medicare coverage. Date Denied The date the MCO denied/paid $0 for the claim due to the other non-Medicare insurance coverage. Report #: 57 Created: 08/27/2011 Name: Potential Subrogation Last Revised: 08/29/2011 Group: Third Party Liability Report Status: Active Frequency: Monthly Exhibits: NA Period: First day of month through the last day of the month. Due Date: By the 15th of the month following the report period. Submit To: Kentucky Department for Medicaid Services Description: Provides report for cases where the MCO’s Member has had an accident and there is potential for a liable third party or subrogation claim. Sample Layout: Potential Subrogation/Liable Party Member Name Member Medicaid ID Date of Injury Subrogation/Liable Party Indicator Attorney/Member Letter Sent Date Attorney/Liable Party Information Lien/Claim Amount Recovered Amount State Notified Date Closed
